Clinical Outcomes of Minimally Invasive Versus Open TLIF: A Propensity-Matched Cohort Study.

In this study, we compare intermediate-term outcomes in minimally invasive surgical transforaminal lumbar interbody fusion (MIS TLIF) to open TLIF. Sixty-four patients who underwent 1- to 2-level MIS TLIF with baseline, 1-, and 2-year outcome measures were identified. These were propensity-matched to a cohort of open TLIF patients based on age, body mass index, sex, smoking status, workers' compensation status, and preoperative outcome measures. At 1 year, both groups had similar improvements in pain and Short-Form 36 (SF-36) Physical Composite Summary (PCS), but the MIS TLIF group had a statistically significantly greater improvement in Oswestry Disability Index (ODI) compared with the open TLIF group. At 2 years, the MIS TLIF group had a statistically significantly greater improvement in pain and ODI compared with the open TLIF group, but no statistically significant difference in SF-36 PCS. Both MIS TLIF and open TLIF lead to significant improvements in clinical outcomes. At 1 year after surgery, MIS TLIF patients had greater improvements in ODI, and at 2 years after surgery, they had greater improvements in pain and ODI. This study showed that the perioperative advantages of MIS TLIF, such as less muscle dissection and faster recovery, continue to be beneficial 1 to 2 years after surgery.

Perioperative complications in revision anterior lumbar spine surgery: incidence and risk factors.

STUDY DESIGN: This is a retrospective review of 129 consecutive anterior lumbar revision surgeries in 108 patients. It is a single-center, multi-surgeon study. OBJECTIVE: To determine occurrence rates and risk factors for perioperative complications in revision anterior lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: Although complication rates from large series of primary anterior fusion procedures have been reported, reports of complication rates for revision anterior fusion procedures are relatively rare. Concern exists chiefly about the risk to vascular and visceral structures because of scar tissue formation from the original anterior exposure. METHODS: This was a retrospective review of 129 consecutive anterior revision lumbar surgeries in 108 patients operated between 1998 and 2003. There were 40 men and 68 women. The age of patients ranged from 25 to 83 (average 50.6 years). Patients were excluded if surgery was for tumor or infection. Patients were divided into 2 groups; those with revision surgery at the same level and those with revision surgery at an adjacent level. Outcome measures included all perioperative complications. Statistical analysis included Student t test and nonparametric sign-rank. RESULTS: The number of surgical levels treated for revision was similar between the 2 groups (1 level 69%; 2 levels 19%; 3 or more levels 12%). Revision cases at the same operative level had a higher overall complication rate (42%) compared with extensions (20%; P = 0.007). This difference was primarily because of vein lacerations (23.7% vs. 3.6%, P = 0.002). There were 2 ureteral problems, both successfully salvaged. There were no arterial injuries or deaths. CONCLUSION: Complication rates for revision lumbar surgery in this series were 3 to 5 times higher than reported for primary lumbar exposures. Complication rates were significantly higher for revision anterior lumbar fusions at the same segment, which were typically in the lower lumbar spine, compared with cases involving extensions, which were typically in the upper lumbar spine.

Impaction allografting for femoral component revision: clinical update.

The technique of cancellous impaction allografting with cement aims to reconstitute a bone-deficient proximal femur while also gaining stable fixation of the femoral prosthesis. Some reports of this technique imply it is a system, requiring not just an exacting surgical method, but also a particular implant design, the polished, double-tapered stem. Other series consider it a surgical technique, and have varied the femoral component design, the method of graft delivery, and other elements of the procedure. Our review evaluates the current literature, with the goal of beginning to ascertain whether published results suggest impaction grafting must be considered a system, requiring a particular stem design, or simply another means to achieve femoral reconstruction in the revision setting. The conclusive answer will require randomized, controlled clinical trials to evaluate particular elements of the procedure, and these studies have yet to be done. However, investigators have shown similarly good short-term to intermediate-term results with various femoral stems at numerous centers. Currently, femoral impaction allografting, whether as a system using particular implant designs or as a surgical technique, is an accepted alternative for revision of a failed femoral component, particularly when bone-stock deficiency is present.

Endogenous cortisol production in response to knee arthroscopy and total knee arthroplasty.

BACKGROUND: There is controversy about whether patients who take exogenous glucocorticoids, such as prednisone, require supplemental (exogenous) glucocorticoids in order to meet the physiological demands of surgery. In this study, we sought to define the magnitude of the surgical stress response in normal patients undergoing major and minor elective orthopaedic surgery. METHODS: A prospective, observational study of thirty patients who had not taken exogenous glucocorticoids and who underwent either elective knee arthroscopy or elective unilateral total knee arthroplasty was performed. Regional anesthesia was used for all patients, and all patients treated with total knee arthroplasty had continuous epidural anesthesia for forty-eight hours after the surgery. The stress response was assessed on the basis of serum and twenty-four-hour urine cortisol levels; comparisons of the urine values were made after correcting for renal function by calculating the cortisol-to-creatinine clearance ratio. RESULTS: Preoperatively, patients undergoing arthroscopy and total knee arthroplasty had similar cortisol-to-creatinine clearance ratios. Patients treated with total knee arthroplasty had a significant (p < 0.001) surgical stress response on the day of the surgery, compared with baseline, whereas patients treated with arthroscopy did not. The mean cortisol-to-creatinine clearance ratio in patients treated with total knee arthroplasty was highest on the day of the surgery and decreased on the third postoperative day. However, on the third postoperative day, the cortisol-to-creatinine clearance ratio still was significantly higher than the baseline value (p < 0.001). Significant differences in the serum cortisol levels also were detected between the patients treated with arthroscopy and those treated with total knee replacement. CONCLUSIONS: Patients undergoing total knee arthroplasty had a significant surgical stress response (a seventeenfold increase in the cortisol-to-creatinine clearance ratio); patients treated with arthroscopy did not. Additional studies, including a prospective trial of patients taking exogenous glucocorticoids, are warranted. Until they are performed, the significantly increased cortisol production observed in non-steroid-dependent patients following total knee arthroplasty leaves open the possibility that steroid-dependent patients undergoing this procedure could benefit from perioperative glucocorticoid supplementation. Since the non-steroid-dependent patients in the present series did not mount a substantial stress response to knee arthroscopy, our results do not support the use of supplemental steroids for that less-invasive procedure.